AMRHEALTH's - Background & Capabilities

AMRHEALTH's - Background & Capabilities

Proven Knowledge Based Solutions for Health Care

Industry Demanding Change and Efficiency
The medical claims payment environment and its reimbursement models are undergoing dramatic changes due to government regulations, rising healthcare costs, complex social and economic issues and the dynamics within the delivery system. The majority of software now in use cannot meet the need for responsible and timely reimbursement processes acceptable to payors, providers and patients alike. And…most of that software is comprised of multiple layers of custom and packaged programs that create complex integration and data management issues. IT departments struggle as they attempt to eliminate fragmentation and keep pace with technology that continues to move at breakneck speed. Development of “smart” software processes that can accommodate both commercial plan models and government assisted models such as Medicare and Medicaid are well beyond the reach of most organizations, including many major managed care organizations within the industry. Many legacy systems now in use are over 25 years old, lack HIPAA compliance, EDI and E-commerce capability and can no longer adapt to the complex shared risk models now being formed among payors and providers. Health care business processes demand higher levels of integration to satisfy this complex decision based information dependent environment causing severe hardships for those organizations that fail to adapt.

Who We Are
Since 1981, AMRHEALTH, a Healthcare Information Technology Company (HIT), has developed, installed, supported and administered business-to-business (B2B) transactions and expert reimbursement processes. Our software supports payors mission critical reimbursement process through enterprise software licensing, consulting or as an ASP(Application Service Provider). Supporting all forms of managed-care delivery, marketing technology and services to insurance companies, third-party administrators, hospitals, HMOs, PPOs, TPAs and self-insured employer groups.

Triadic Operability™ integrates medical and clinical coding policies, provider contracts and guidelines and health plan business rules into one set of highly efficient and integrated claims adjudication and administration platforms. Using EDI and the Internet for real-time claims adjudication to connect providers, payors and other healthcare trading partners through intelligent integration, and redefining the meaning of responsible reimbursement. AMRHEALTH’s real time processes have addressed HealthCare’s most troubling issue…timely and accurate reimbursement of medical claims.

As a developer of “expert” reimbursement and decision support technology since 1981.
As a technology centric “consultant”, used by leading managed care organizations.
As an “Application Service Provider” delivering online adjudication and real time payment of medical claims via the Internet.

As an “industry leader” with 2 of every 3 Physicians in the US utilizing AMRHEALTH solutions for their own individual Catastrophic Major Medical, Medicare Supplement and Indemnity needs.
As an “early adopter” of RBRVS, NCCI and HIPAA standards.

Industry Leadership
Combining in-depth experience, commitment to quality, and an ability to orient itself to the changing needs of the marketplace, AMRHEALTH integrated framework of decision support processes that have improved health plan performance for our clients. These include such notable organizations as The American Medical Association, Union Pacific Railroad, Aetna and Extendicare. In 1997 and 1998, AMRHEALTH was awarded Federal Grants from the Health Care Financing Administration(HCFA), now Centers for Medicare & Medicaid Services(CMS), for our innovation with developing the Advanced Value Scale (AVS) process, a clinical edit system utilizing Resource Based Relative Value Scale (RBRVS) edits and pricing coupled with National Correct Coding Policy Initiatives (NCCI). Integrated with an advanced claims adjudication engine, we now offer the world’s first fully integrated reimbursement platform…that improve the efficiencies and effectiveness of transacting business between healthcare stakeholders.

Commitment
Responding to each client’s needs, personally and professionally, as if they were our own. We strive to distinguish ourselves in five key areas:

Product Quality
Professional Competence
Un-compromised Client Service
Industry Leadership
Technical Innovation

Seeking to establish lasting relationships with our clients based on the value delivered through our products and services. We commit, in advance, to a mutually determined course of action, confident that the end result will be more, not less, than we promised.

Integrated Solutions
Delivering end to end solutions that address a payor’s mission critical needs including claims entry and adjudication, coding compliance, group administration, billing and enrollments, HMO/PPO management, EDI, utilization management, HIPAA transaction compliance and provider contract management. The AMRHEALTH architecture puts complex functional processes easily together with knowledge-based processes and databases. Our solutions elevate our clients processes to new levels of sophistication that can spot physician overcharges and poor practice patterns. Our clients can now design, build and administer their health palns with processes that respond to the health care challenge ... containing costs!!!.

Product Advancements
Providing stand-alone, Internet and Application Service Provider (ASP) deployment of our advanced software solutions. Distributing technology and shared professional services through virtual private networks for lowering the cost of information technology and improving the performance of health plans.

AMRHEALTH fully connects providers, payors, employers and employees with a integrated processing infrastructure over the Internet. With extensive experience in developing integrated systems, AMRHEALTH solutions give our clients easy access to integrated, valuable information and enterprise-wide functionality. Tailored to our clients’ requirements and providing real connectivity and integration to transform their legacy systems to operate in the new health care economy.

The company aligns itself with the overall trends of the industry, clearly realizing that it must take careful yet proactive steps toward developing new solutions that meet industry needs ahead of the needs of its clients.

Assuring Quality “Performance Plus”
Since the beginning, we have been responding to the market’s demand for an enhanced and more comprehensive offering of quality products that reduce the cost of software ownership. The company continually addresses this changing demand through successful internal development standards, proven change management systems, quality improvement programs and the Internet. Our “Performance Plus Software” is a comprehensive quality assurance program which elevated internal development process to new levels of quality...delivering added value to our clients’ bottom line. Software Solutions are fully documented, maintained with strict change control procedures and updated regularly. Customers subscribing to the Performance Plus concept gain the benefit of regular product enhancements and modifications.

The Vision
As a proactive developer of decision support software, our vision has begun to reshape the future for conducting business on the Internet. Reinventing responsible reimbursement through our integrated technology framework. Using the Internet, we go well beyond connecting…we integrate. It is a vision that has transformed a complex and inefficient claims payment system into a totally integrated reimbursement process to integrate processes for providers, payors, employers and employees. It takes advantage of the latest information systems technology and allows our clients to redefine their role from health insurer and claims processor to proactive managers of health care.

The Spirit
The AMRHEALTH spirit embodies the belief that we can be the best by offering a quality product with a high level of service and support combined with a desire to address the needs of the client no matter what.

Integrated Intelligent Solutions

Intelligent Claims Administration and Processing System
(ICAPS) is an end to end integrated reimbursement and claims adjudication engine supporting managed-care delivery systems. Utilizing Rules Based decision support processes including automating claims processing including advanced coding and compliance logic to eliminate coding and payment errors. Triadic Operability integrates all of the necessary payment rules from payors, provider contracts and industry standard medical and clinical compliance into one seamless consistent error free architecture.

Eliminating Fraud and Abuse and Controlling Costs
Advanced Value Scale (AVS) is a complete code management system that eliminates fraud and abuse. AVS provides clinical coding logic and knowledge bases that conform to AMA CPT(R) coding, CMS policy and National Correct Coding Initiative. CPT is a registered trademark of the American Medical Association. Over 130 clinical edits are already part of AVS with more added daily. AVS can accommodate Medicare as well as commercial plan rules and can be tailored to individual contracts. It can support multiple lines of businesses by provider specialty with the ability to address a payor’s specific audit workflow process.

Resource Based, Usual, Customary and Responsible
RB-UCR is the first responsible and reasonable database tool that utilizes RBRVS and NCCI standards to establish pricing benchmarks and payment thresholds for physician medical payments. Delivered in a variety of media formats and designed to integrate to existing legacy applications.

Getting Money Back From Existing Health Plan or Servicer
Cost Containment Audit and Review Service (CCARS) take back control of your plan and money. Real time retrospective audit of past claims identifies problem areas for future claims and contracts. Find and recover outliers, procedure errors, high volume, high individual, high provider as simple as 1,2,3. Non- Invasive, nothing to install or integrate with typical ROI of 5% or more.

Advanced features for effective cost containment-

Fully integrated business rules
Medical, Dental, Anesthesia, Disability in one common architecture
Case Management with guidelines
Real time adjudication engine
Internet and ASP deployment
Workflow management
HIPAA transaction processing
Document scanning and OCR workflow improvement
Complete Physician Coding and Management System with RBRVS Pricing and Editing
Electronic Media Claims Processing (EDI)
Insurance Premium Billing and Accounts Receivable
Provider Credentialing
Anesthesia Pricing Calculator Tool for Anesthesia Services
Claims Analysis and Evaluation
Integrated care management search engines
PPO re-pricing

CAPABILITIES - AMRHEALTH develops and support technology-based, cost-containment, and decision support solutions and services for health clients worldwide. Our clients include health plans, PPOs, Hospitals, managed-care organizations, TPAs and large employer groups.

SOFTWARE PRODUCTS - Expert systems supporting all forms of integrated managed-care delivery systems.

APPLICATION SERVICE PROVIDER
Efficient deployment of technology coupled with expert professional services through the Internet and virtual private networks (VPN).

ONLINE ADJUDICATION, INSTANT PAYMENT - Utilizing our patent pending business process that allows providers to enter and adjudicate claims in a real time environment through the Internet.

CLAIMS RE-PRICING - We can serve as the technology manager for provider groups to accommodate claims re-pricing and network administration.

BENEFIT PLAN DESIGN - Review and analysis of current benefit plan designs and development of more cost-effective benefit programs.

RISK EVALUATIONS - Develop fully funded and partially funded benefit designs, which allow for full integration of managed care cost containment programs.

THIRD PARTY ADMINISTRATIVE SERVICES - Complete claims administrative services for processing self-funded and partially self-funded benefit programs which support medical, dental, disability, prescription drug and dental.

MEDICARE AND MEDICAID SPECIALISTS - Experts in coding reimbursement and physician bill editing to conform to all current statutes and regulations from CMS and the National Correct Coding Initiative.

FEE SCHEDULE DEVELOPMENT - Complete fee schedule analysis and development for use in managed care arrangements.

RBRVS REIMBURSEMENT DESIGNS - Conversion from UCR to RBRVS reimbursement processes for use in evaluating contract arrangements and for developing physician compensation plans.

CLAIM REVIEW AND AUDITING - We deploy expert systems for evaluating physician bills and reimbursement processes that conform to accepted national standards.

COST CONTAINMENT SERVICES - Balanced cost containment solutions for health plans, employees, and providers.

CONSULTING SERVICES - A complete suite of management on information technology services.

Complete Information System
Evaluations
TPA Audit
HIPAA exposure and assessment
Work Flow Analysis
System Analysis
Self-administration Transition Planning

APPLICATION DEVELOPMENT - Experienced system professionals that help our clients take full advantage of the latest technology.

PROJECT MANAGEMENT - Complete conversion planning and implementation.

On-site Training
Conversion Planning
Data Conversion Services